Acute Renal Failure, Fluid Management and Renal Replacement Therapy

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Acute Renal Failure, Fluid Management and Renal
Replacement Therapy

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• V.S???

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Outline

• Renal function
• Acute renal failure
• Complication of ARF
• Management
• Renal replacement therapy

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• ????? Vitamin D, erythropoietin

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Outline

• Renal function
• Acute renal failure
• Complication of ARF
• Management
• Renal replacement therapy

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Definition

• rapid (hours to weeks) decline in glomerular
  filtration rate and retention of waste products
• Lack a uniform definition
• Cr gt 1.5x, urine output lt.5ml/kg/hr
• Cr increase 1.0 mg/dl/2d
• Incidence
• 5 of hospital admission
• up to 30 of admission to intensive care units.

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Prerenal azotemia

• Intravascular volume depletion (hypovolemia)
• Major trauma, burns, crush syndrome, hemorrhage,
  dehydration
• GI fluid loss vomiting, surgical drainage,
  diarrhea
• Renal fluid loss diuretics, osmotic diuresis,
  adrenal insufficiency
• Sequestration of fluid in extravascular space
  pancreatitis, peritonitis, hypoalbuminemia

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Classification of Renal Failure

• (1)  Prerenal abnormality (Prerenal azotemia)
  disorder of renal hypoperfusion which
  intrinsically normal
• (2)   Intrinsic renal abnormality (renal
  azotemia) disease of the renal parenchyma
• (3)   Postrenal abnormality (postrenal azotemia)
  acute obstruction of urinary tract

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Prerenal Azotemia

• Decreased cardiac output (low cardiac output)
• Severe congestive heart failure or low cardiac
  output syndrome myocardial failure, valvular or
  pericardial disease, including arrhythmias and
  tamponade
• Pulmonary hypertension, massive pulmonary
  embolism
• Positive pressure mechanical ventilation

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Prerenal Azotemia

• Increased renal /systemic vascular resistance
  ratio
• Systemic vasodilatation sepsis, antihypertensive
  agents, afterload reducers, anesthesia,
  anaphylaxis
• Renal vasoconstriction hypercalcemia,
  norepinephrine, epinephrine, cyclosporin,
  amphotericin B
• Liver cirrhosis with ascite

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Prerenal Azotemia

• Increased blood viscosity (hyperviscosity
  syndrome)
• Multiple myeloma, macroglobulinemia, polycythemia
• Renal hypoperfusion with impairment of renal
  autoregulatory responses
• Renal artery obstruction artherosclerosis,
  embolism, thrombosis, dissecting aneurysm
• Cyclooxygenase inhibitors, angiotension-converting
  enzyme inhibitors

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Intrinsic Azotemia

• Acute tubular necrosis
• Ischemia as for prerenal azotemia, obstetrical
  complication (abruptio plancentae, postpartum
  hemorrhage)
• Nephrotoxic damage contrast media, antibiotics
  (e.g. aminoglycosides, amphotericin B),
  cyclosporine, chemotherapeutic agents( e.g.
  cisplatin), organic solvents (e.g. Ethylene
  glycol), heavy mental, snake venom, mushrooms,
  sulfonamide
• Pigment nephropathy myoglobin,
  hemoglobintumor-specific syndrome plasma cell
  dyscrasia, tumor lysis

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Intrinsic Azotemia

• Disease of glomeruli or renal microvasculature
• Glomerulonephritis and vasculitis
• Hemolytic uremic syndrome, thrombotic
  thrombocytopenic purpura, disseminated
  intravascular coagulation, toxemia of pregnancy,
  accelerated hypertension, radiation nephritis,
  scleroderma, systemic lupus erythematosus

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Intrinsic Azotemia

•   Interstitial nephritis
• Allergic antibiotics (e.g. beta-lactams,
  sulfonamides, trimethoprime, rifampicin),
• Cyclooxygenase inhibitors, diuretics, captopril
• Infection bacterial (e.g. acute pyelonephritis,
  leptospirosis), viral (e.g. CMV), fungal
• Infiltration lymphoma, leukemia, sarcoidosis

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• Intrinsic Azotemia

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Intrinsic Azotemia

• Renal vein obstruction thrombosis, compression
• Intratubular deposition and obstruction
• myeloma proteins, uric acid, oxalate, acyclovir,
  methotrexate

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Postrenal Causes of Renal Failure

• Obstruction of ureters
• Extraureteraltumor cervix, prostate,
  endometriosisPeriureteral fibrosis
  (retroperitoneal fibrosis)accidental ureteral
  ligation during operationIntraureteral stone,
  blood clots, pyogenic debris, papillary necrosis
• Bladder neck obstruction
• Neurogenic bladder, bladder carcinoma, prostate
  hyperplasia, calculi
• Urethral obstruction
• Stricture, phimosis, congenital valve, tumor

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Symptoms and Signs

• Retention of nitrogenous waste products
• Nausea, vomiting, diarrhea, hiccup, foul taste,
  dry crusted mouth, itching,
• Drowsiness, clouding of consciousness,
  neuropathy, pericarditis, GI bleeding,
• Coma
• Retention of salt and water
• Pulmonary edema, peripheral edema, ascites,
  pleural effusion

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Symptoms and Signs of Renal Failure

• Retention of potassium
• Weakness, lassitude, paralysis, EKG changes with
  tenting T waves, widening of
• QRS complex, increased PR interval, sine wave
  pattern, cardiac arrest, VT
• Retention of acid
• Kussmaul respiration, hyperreflexia, hypotension

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• Edema
• Impairment of renal function

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Outline

• Renal function
• Acute renal failure
• Complication of ARF
• Management
• Renal replacement therapy

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Complications of Renal Failure

• Cardiopulmonary complication
• Metabolic complication
• Gastrointestinal complication
• Neurogenic complication
• Hematological complication
• Infection

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Cardiopulmonary Complications

• Cardiovascular
• Pulmonary edema
• Arrhythmia
• Hypertension
• Pericardial effusion
• Myocardial infarction
• Pulmonary embolism
• Congestive heart failure

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Hypertension and Edema

• Inability of the kidney to excrete sodium ? blood
  volume ? ? hypertension and edema

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Metabolic Complications

• Metabolic
• Acidosis
• Hyponatremia
• Hyperkalemia
• Hypocalcemia
• Hyperphosphatemia
• Hypermagnesemia
• Hypomagnesemia
• Hyperuricemia

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Metabolic Acidosis

• Inability of the kidney to secrete hydrogen ions
  and conserve bicarbonate

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Hyperkalemia

• K competes with H for Na exchange ? Tubular
  excretion of potassium ? ? Hyperkalemic acidosis
• Excretion of aldosterone ? ? Excretion of
  potassium in collecting duct ? ? Hyperkalemia

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Gastrointestinal Complications

• Gastrointestinal
• Nausea
• Vomiting
• Gastritis
• Gastroduodenal ulcer
• Gastrointestinal bleeding
• Malnutrition

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Neurogenic Complications

• Neurogenic
• Asterixis
• Neuromuscular irritability
• Mental status changes
• Somnolence
• Coma
• Seizure

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Hematological Complications

• Hematological
• Anemia
• Hemorrhagic bleeding
• Infection
• Pneumonia, septicemia
• Urinary tract infection, wound infection

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Anemia

• Erythropoietin decrease
• Erythropoietin stimulates bone marrow to produce
  red blood cells.
• Toxic wastes suppress the ability of bone marrow
  to produce red blood cells.

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Bleeding

• Platelet abnormality
• Normal or a little decreased platelet number
• Platelet dysfunction
• Epistaxis, GI bleeding, bruising, hemoptysis

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ARF VS ALI

• Mortality
• ARF 30-40
• ALI 35
• BOTH 80

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ARF VS ALI

• Effect of ARF on lung ( Experimental studies)
• Increase pulmonary vascular permeability,
  macrophage medicated in part
• Salt and water transporters disorder lung fluid
  retention

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ARF VS ALI

• Effect of mechanical ventilator on kidney (
  Experimental studies)
• Systemic hemodynamic change( VR, CO )
• Anti-natriuretic, anti-diuretic effect
• Augmentation of inflammatory milieu

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Outline

• Renal function
• Acute renal failure
• Complication of ARF
• Management
• Renal replacement therapy

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Management

•    Prevention
•    Etiology treatment
•    Prevention additional injury
•    Establish diuresis
•    Treatment of complication
•    Conservative measurement
•    Renal replacement therapy

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Prevention

• Identification of high-risk patients for
  pharmacologic agents-induced nephrotoxicity
• iodinated radiocontrast medium, NSAIDs
• Aggressive surveillance for nephrotoxin-induced
  renal dysfunction
• cisplatin, amphotericin B, aminoglycoside
• Use of volume expansion in selected clinical
  settings
• Hyperpigmenturia hemoglobinuria, myoglobinuria
• Crystaluria uric acid, acyclovir, methotrexate,
  sulfonamides
• Minimalization of catheters use to avoid
  nosocomial sepsis

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Etiology Treatment

• Correct postrenal factor
• Correct prerenal factor
• Treat underlying sepsis
• Stop nephrotoxic drugs

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Establish Diuresis

• Volume expansion/hydration
• osmotic diuretics and loop diuretics mannitol,
  furosemide
• renal vasodilators dopamine (1-2ug/kg/min),
  atrial natriuretic peptid

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Evaluation of intravascular volume
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Guide of Volume Expansion

• CVP 8-14 cm H2O (5-2 rule)
• PAWP 12-16 mmHg (7-3 rule)
• Urine output 0.5-1.0ml/kg/hour
• Weighing the patient daily
• Insensible water loss from the skin and
  respiratory tract (500 ml/day)

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Conservative Measurement

• Fluid balance
• Careful monitoring of I/O and body weight
• Fluid restriction
• (usually less than 1 L/day in oliguric ARF)
• Total intake lt urine output extrarenal losses
• Electrolytes and acid -base balance
• hyperkalemia
• hyponatremia
• Keep serum bicarbonate gt15
• hyperphosphatemia
• Treat hypocalcemia only if symptomatic

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Dietary modification

• total caloric intake 35 50 kcal/kg/day
• to avoid catabolism
• Salt restriction 24 g/day
• Potassium intake 40 meq/day
• Phosphorus intake 800 mg/day

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Conservative Measurement

• Uremia-nutrition
• Restriction protein but maintain caloric intake
• Carbohydrate 100gm/day to minimize ketosis and
  protein catabolism
• Drug
• Review all medication, Stop magnesium-containing
  medication
• Adjusted dosage for renal failure, Readjust with
  improvement of GFR

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Outline

• Renal function
• Acute renal failure
• Complication of ARF
• Management
• Renal replacement therapy

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Indications for Renal Replacement Therapy

• Prophylactic dialysis BUN 80-100 mg/dl ,
  creatinine 8-10 mg/dl
• Volume overloading with refractory to diuretics
• Pulmonary edema
• Hyperkalemia gt 6.5 mEq/l
• Severe metabolic acidosis lt 7.2

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Indications for Renal Replacement Therapy

• Uremic pericarditis
• Uremic encephalopathy coma, seizure
• Acute uric acid nephropathy

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Methods for Renal Replacement Therapy

• Intermittent hemodialysis
• Peritoneal dialysis
• Continuous renal replacement therapy
• CAVH/CAVHD/CVVHDF, CVVH/CVVHD/CVVHDF

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Mechanisms

• diffusion movement of solute towards the same
• concentration on each side of
  membrane.
• convection solute is carried together
  with solvent
• across the membrane by
  filtration.
• ultrafiltration plasma water and
  crystalloids separated
• from the whole blood across a
  semipermeable
• membrane in response to a TMP.
• osmosis operates in peritoneal dialysis.
• ( glucose is the osmotic agent )

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HD
HF
HDF
HFD
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Intermittent hemodialysis in ARF and critically
ill patients
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Peritoneal dialysis

• infusion of pyogen-free solution into the
  peritoneal cavity, drained in subsequent cycles.
• Mechanism diffusion, convection, and osmotic
  ultrafilation
• Modalities intermittent peritoneal dialysis (
  IPD ), continuous equilibrated peritoneal
  dialysis ( CPD ), tidal peritoneal dialysis ( TPD
  ).
• Indications patients at risk of bleeding
• fluid overload in CV
  instability

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Peritoneal dialysis
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Continuous renal replacement therapy

• ??
• ????????????(CAVH)
• ????????????(CVVH)
• ????????????(CAVHD)
• ????????????(CVVHD)
• ??????????????(CAVHDF)
• ??????????????(CVVHDF)

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CAVH
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CVVH
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Comparison of different CRRT Modalities
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• ???????????,??????,????????????? (???, ??)
• ??????????????
• (1) ???????
• (2) ???????????(?TPN)
• CRRT????????????,?????????????(intermittent
  hemodialysis, IHD)??????

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CRRT ????

• 1.?????
• 2.?????????????
• convective clearance (hemofiltration)
• diffusive clearance (hemodialysis)
• ??????(HDF)
• 3.???????
• arteriovenous v.s. venovenous

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CRRT????

• A. Renal indications
• -hemodynamic instability
• -multiple organs dysfunction syndrome
• accompanied by renal failure
• -acute renal failure with cerebral edema
• B. Non-Renal indications
• -possible removal of substances active as
  mediators

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CRRT ???

1. avoidance of electrolyte, water and urea
   fluctuation
2. gradual urea removal
3. hemodynamic stability with slow ultrafiltration
4. optimal fluid balance and unlimited alimentation
5. elimination of septic mediators
6. lower intracranial pressure
7. improved outcome

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CRRT???

• ?????(?CAVHD)
• ?????(???????)
• limited mobility
• slower solute and fluid removal
• ???????

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?????? (replacement fluid)

• ?? plasma water
• approximate normal plasma water composition,
  replacing electrolytes and minerals
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?????(1)

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  ?
• ??????????????????????????????????
• ???????????????????????

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?????(2)

• ??????????????,?????????????,?????????????????????
  ?????
• ?? CV(A)VHD total sodium mass
• transfer convection diffusion
• (?? convection??)

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?????(1)

• ??????????????,??????
• ??????,??,???? hypercatabolism,
• GI bleeding, sepsis, hemolysis, hematoma,
• crush syndrome???????????????
• ??????? 1-2 mEq/L ?
• ???????????????????????
• ????????hypocalcemia,
• hyponatremia, acidosis, hypermagnesemia
• ????????????????????

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?????(2)

• ???????,????????? ??(30),??????????????,?????????
  ??????,?????????????
• ??CRRT?????????????????????????,??????????(???)???
  ????

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?????(3)

• ??????????????????CRRT????????????????????????,??
  ????????????????????
• ??????????,?????????,??????????

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?????

• ??hemofiltration?, ????????,??????(?70????)
• ????????? 1.5-1.7 mEq/L

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????

• CVVHD ?? clearance 21.3 5.6 cc/min ( v.s. BUN
  25.3 cc/min , Cr 24.1 cc/min)
• ??90?????,?????????????????
• ???????????

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??

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• ?????????????????,???
• ?????????????
• 2. ??hemofiltration ???, ?????
• ???, ??????????????????????????hemodialysis?
  ????
• ????????????????????

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• 3. ?????????????/????
• ???????????????,?
• ???????????,?????
• ?,???????????